Muzaffer Altindas

The Prefabricated Temporal Island Flap for Eyelid and Eye Socket Reconstruction in Total Orbital Exenteration Patients A New Method

Anophtalmic socket reconstruction is a challenging problem in plastic surgery. We had described a prefabricated superficial temporal fascia island flap and used this technique in >50 enucleation patients with severe socket contraction ending in excellent or good results for 28 years (Altindas-1 procedure). However, the flap was not suitable for the exenteration patients with complete eyelid loss. The technique was modified and used in exenteration patients (Altindas-2 procedure). In this 2-staged procedure, the temporoparietal fascia is prefabricated with a full-thickness skin graft from the retroauricular area, and a strip of scalp is preserved at the middle of the flap. The flap is transferred to the orbit through a subcutaneous tunnel at the second stage. The prefabricated flap is used for the reconstruction of eyelids and periorbital skin; scalp island is used for the reconstruction of lid margins and eyelashes; and the neighboring bare temporoparietal fascia is used for the augmentation of the periorbital soft tissues. The orbital lining is elevated as a centrally based skin flap and used for the reconstruction of the eye socket, fornicles, and posterior lining of the eyelids. The technique was used successfully in 5 total exenteration patients with complete eyelid loss. In 1 patient, the ipsilateral temporal island flap was used previously, and the flap was prepared from the contralateral site and transferred to the anophtalmic orbit as a free flap 5 weeks later. By this procedure, it is possible to reconstruct a stable eye socket that is suitable for ocular prosthesis, upper and lower fornicles, periorbital skin with good color matching, naturally looking eyelids with eyelashes and lid margins, and medial and lateral canthal areas. It is also possible to improve periorbital soft tissue atrophy, which is an important problem in patients who had radiotherapy previously. Free transfer of the flap provides a new solution for the reconstruction of cases that were operated previously.

A new limb-salvaging technique for the treatment of late stage complicated Charcot foot deformity: Two-staged Boyd's operation.

BACKGROUND Depending on the stage of disease, several operative and non-operative treatment options exist for diabetic patients with Charcot foot deformity. In the early stages of the disease, the most effective treatment is total-contact cast application. In patients with multiple bone fractures and deformations, surgical interventions are generally required for the reconstruction of foot architecture. Exostectomy, osteotomy, arthrodesis, and internal-external fixation are some of these operative methods. However, recurrence of ulcer and infection is very likely following these surgical procedures. If the lesion and infection reach to midfoot and hindfoot region, a major amputation is usually required for treatment. METHODS We have been performing Boyds operation for the last 10 years in diabetic foot patients who had complicated lesions in midfoot and hindfoot regions. Furthermore, since 2004, we have been doing the same operation for complicated Charcot foot deformities. So far, we have treated 11 patients. RESULTS The mean age of the patients was 53.4±10.2 years, and the mean duration of diabetes mellitus (DM) was 17.5±7.2 years. All patients had chronic infections with fractures of the tarsal bones for at least 2 years. Durable wound coverage and ankylosis were achieved in all patients with two-staged Boyds operation. No recurrence is detected in any of the patients during mean post-operative follow-up period of 2.1±0.8 years. CONCLUSION Boyds operation is a reliable option for the treatment of patients with late stage Chatcot foot deformity.

The Epidemiology of Foot Wounds in Patients with Diabetes: A Description of 600 Consecutive Patients in Turkey

Epidemiological studies describing demographic, clinical, and surgical characteristics of diabetic foot wounds are lacking in Turkey. To further describe the epidemiology of diabetic foot wounds in Turkey, we developed an evaluation form and performed a retrospective cohort study that entailed 600 diabetic patients who were admitted to the hospital for treatment of their foot wound(s). The mean age of the cohort was 62.3 ± 10.3 (range 23-92) years, and their mean duration of diabetes was 17.4 ± 7.4 years. Males accounted for 68.17% of the cohort, and 96.83% of the cohort had type 2 diabetes. Prevalences for lower extremity arterial pulses and peripheral neuropathy, as well as the location, depth, microbiology, and surgical treatment of the pedal wounds are also presented. In conclusion, diabetic foot wounds are common in Turkey, and the morbidity associated with these lesions is generally substantial. Although our investigation aimed primarily at describing risk factors associated with diabetic foot wounds, we believe that the findings of this investigation can be used in the development of prospective cohort studies and randomized controlled trials that focus on foot wounds in diabetic patients in Turkey, and may be useful to investigators in other parts of the world.

Is Boyd's Operation a Last Solution that May Prevent Major Amputations in Diabetic Foot Patients?

We had several difficulties in dealing with diabetic foot lesions and infections at the level of midfoot and hindfoot. At this level of the foot, bone and joint involvement is quite common. We had to perform major amputations in most of these patients. As our search to overcome this problem continued, we concluded that the relationship between infection, necrosis, and hypo-avascular tissue is very strong in this part of the foot. At the end, we have seen that Boyds operation can break this vicious cycle. Boyds operation consists of talectomy, excision of articular surfaces of tibia and calcaneus, and tibiocalcaneal arthrodesis. It can be performed as single or 2-staged operation depending on clinical judgment. After the first stage of operation, the defect is left open for a period. With local wound care, the defect is prepared for definitive closure and closed secondarily. We have performed Boyds operation in 16 patients with diabetic foot lesions and infections reaching midfoot and hindfoot regions. In 15 patients, complete healing was achieved and these patients were able to walk themselves. Mean follow-up period was 3.2 years. Most of the time the heel region and calcaneus are not on the pathways of severe foot infections. Therefore, the most important criterion that is necessary to perform Boyds operation usually do exist. After the Boyds operation, an optimal condition for wound healing is achieved by removing all bradytrophic (hypovascular) tissues in the foot. Boyds operation is superior to other partial midfoot and hindfoot amputations in terms of anatomy and function.

A reliable method for treatment of nonhealing ulcers in the hindfoot and midfoot region in diabetic patients: reconstruction with abductor digiti minimi muscle flap.

AbstractThe foot has a unique anatomic composition and a perfect architecture, which is necessary for mobilization. However, this complex structure is also responsible for healing problems in foot reconstruction. After 25 years of experience in diabetic foot surgery practice, we observed that some hindfoot ulcers are like an iceberg in that they have much more involvement in the plantar fat pad than the skin, and the lateral midfoot region is a common site for ulcer formation. Also the fifth tarsometatarsal joint region is a prominent anatomic structure vulnerable to repetitive trauma and ulcer formation that may easily spread to other parts of the foot. These ulcers should be reconstructed with well-vascularized tissues such as muscle flaps after debridement. Between 2003 and 2010, 17 diabetic patients with foot ulcers, involving bone and joint, were reconstructed with abductor digiti minimi muscle flap. When it is needed, the flap is covered with a small split-thickness skin graft. In all cases, complete healing was achieved. The muscle flap functioned well as a versatile and shock absorbent coverage without recurrence of the ulcer during a mean follow-up period of around 2 years. Diabetic foot ulcers should be evaluated and treated individually depending on their location and affected tissue composition. The most appropriate reconstructive option should be selected for each lesion. The abductor digiti minimi muscle flap is extremely useful for the reconstruction of small- to moderate-sized defects that have exposed bone, joint, or tendons in the hindfoot and lateral plantar midfoot.

A reliable surgical approach for the two-staged amputation in unsalvageable limb and life threatening acute progressive diabetic foot infections: Tibiotalar disarticulation with vertical crural incisions and secondary transtibial amputation

BACKGROUND If all efforts to treat acute progressive diabetic foot infection remain insufficient, the decision of major amputation should be undertaken. For this purpose, guillotine amputation is usually performed first. However, guillotine amputation below the knee level may cause the corresponding infection to spread to preserved anatomical spaces. METHOD First stage of our procedure consists of tibiotalar disarticulation and vertical incisions performed throughout the lower leg to remove the septic foot and drain the compartments. During the interval period, appropriate antibiotherapy and wound care are applied. After the interval period, definitive transtibial amputation is performed in the second stage. RESULTS Fifty-nine percent of the 62 transtibial amputations were healed completely. Failure developed in 3 cases which required opening of the amputation stump. In one patient, revision amputation at a higher transtibial level was done. Infection and necrosis reached to the knee joint in the other two patients and transfemoral amputation became the only treatment option for these 2 cases. CONCLUSION Tibiotalar disarticulation with vertical lower leg incisions as a first stage of two-stage transtibial amputation is a safe and reliable method. It reduces the risk of unnecessary tissue sacrifice and failure rate of the secondary transtibial amputation.

Re: A benign Schwannoma of the digital nerve distal to the proximal interphalangeal joint

A 38 year-old labourer sustained distal radius and midshaft ulnar fractures after a fall. He was treated by open reduction and internal fixation of both bones elsewhere. The ulna was fixed with a dynamic compression plate and the distal radius with a fixed-angle volar plate (Hand Innovations, Miami, FL, USA). He presented to our clinic 2 2 years after surgery complaining of prominent painful hardware and wanted both plates removed. On physical examination, the patient was found to have tenderness to palpation over both plates. Under anaesthesia, the ulnar plate was exposed and removed without difficulty. The radial plate was exposed and the two proximal 3.5mm shaft screws removed with a standard large fragment screwdriver, without difficulty. However, removing the four distal fixed-angle locking 2.5mm partially threaded screws proved to be extremely difficult. One screw was removed with a power screwdriver after a few failed manual attempts. One screw could only be unscrewed by 2mm, after which it became lodged and would not loosen further. The other two screws were half removed until the point when the trailing threads began to engage the volar radial cortex, after which they also became lodged. Multiple tools were used in the attempted removal of the three screws to no avail, and the screws eventually became stripped. A last attempt was made to divide the screws with an osteotome between the plate and the radius, but this also proved ineffective and removal of the plate was abandoned. A Midas Rex metalcutting attachment (Medtronic, Minneapolis, MN, USA) was used to remove the prominent parts of the screws flush with the plate and to smooth the rough edges of the plate. The plate and buried portions of three screws were left in situ. Postoperative recovery was uneventful and, 6 months after surgery, he had recovered the same (functional) range of motion of the wrist and digital joints as pre-operatively, but with slight volar wrist pain. Volar plating of distal radial fractures has emerged as a popular method of treatment, and advocates of this technique of plating favour it over the dorsal approach as the fixed-angle device is less prominent and causes less tendon irritation or risk of tendon rupture (Smith and Henry, 2005). However, with increasing use, complications have also surfaced. Rupture of the flexor pollicis longus tendon is of most concern and has led some to support routine removal of volar plates (Drobetz and Kutscha-Lissberg, 2003). The exact reason why the screws could not be removed in this case is unclear. It is possible that a contributing factor was healing new bone formation under the plate. Perhaps because of the extended time since primary surgery (2 2 years), a new bone overgrew both the leading and trailing titanium screw threads. The partially threaded screws may have been responsible. It was possible to back out these relatively weak screw threads to the point where it seemed that the trailing threads were engaging the dense near cortex. Overgrowth of the cortex and/or inability of the partially threaded screws to back out through this cortex then prevented the screws from being retrieved. The purpose of this communication was not to dissuade colleagues from using volar plates, but to make the surgical community aware of this complication. Removal of these plates should be done only if absolutely necessary and with awareness of the possibility of difficulty in retrieving the distal screws.

A Novel and Alternative Treatment Method for Diabetic Heel Ulceration Exposing the Calcaneus Which Is Not Suitable for Flap Surgery: Vacuum Assisted Sandwich Dermal Matrix.

Background. Currently, free flaps and pedicled flaps are the first treatment choices for large heel ulcer reconstruction. However, flap reconstruction of heel ulcerations cannot be performed in all diabetics especially with concurrent severe peripheral vascular disease because of higher flap failure rate. In recent years, the use of acellular dermal matrix (ADM) has emerged as an alternative treatment option for extremity ulcers. Methods. We present 13 diabetic patients with a large heel ulceration exposing the calcaneus, who were not eligible for flap surgery due to the presence of only one patent artery of trifurcation. These cases were treated with the vacuum assisted sandwich dermal matrix (VASDEM) method. Results. None of the patients required amputation. Skin grafting was successful in ten patients. Although partial losses were observed in three patients, they were healed spontaneously without surgical interventions. During the follow-up period none of the patients developed ulceration on the treatment area. All patients maintained their preoperative ambulatory ability. Conclusion. VASDEM is a novel method offering opportunity for treatment before proceeding to amputation in diabetic heel ulceration exposing the calcaneus which is not suitable for flap surgery. It also has the potential to close wounds of all sizes independent of the vessel status and wound size in selected diabetic patients.

INTERNAL PEDAL AMPUTATION IN DIABETIC FOREFOOT ULCERS

Objective Approximately 80 percent of diabetic foot wounds arise from the front foot. Most of these wounds are associated with bone and joint involvement. Toe amputations and ray amputations are the most frequently performed surgical interventions for the lesions limited to front foot. Many diabetic patients refuse surgery although they have advanced deformities that may cause dangerous injuries. Considering these patients, we defined a new alternative surgical procedure protecting the external appearance of the toe. This surgical procedure is not perceived by patients as a toe-consuming operation. Materials and Method Between 01-04-2004 and 08-11-2012, 76 toe lesions of 66 diabetic patients were treated with a new surgical approach. 50 patients were male and 16 were female. Mean age was 60.4, mean duration of diabetes was 16,6 years. Results The mean follow up duration was 26.4 months (range 12.0 to 71.4). In 47 patients, the surgical closure healed by primary intention (81%). Dehiscence occurred in 11 patients (19%). Infection of the surgical wound developed in four patients (6,9%). Ulcer relapse occurred in three patients (5.1%). In six patients (10.3%), an ulcer developed in the contralateral foot. Long term follow up revealed that almost the same or approximately close toe length and width without any deformity were seen in 66 toes (in 58 patients). Conclusion Removal of the involved bone and other involved tissues while preserving the skin and other healthy tissues to reconstruct an acceptable new toe is possible in this new technique.